Information Collection

IPE, Site Characteristics and Outcomes

IC 272957 under ICR 202412-0906-005 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 IPE, Site Characteristics and Outcomes	Form and Instruction
4 IPE, Site Characteristics and Outcomes IPE-HC_30 day_final.pdf	Form and Instruction
4 IPE-HC_draftfinalOMB 05.29.2025 IPE-HC_draftfinalOMB 05.29.2025.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4	IPE-HC_draftfinalOMB 05.29.2025	IPE-HC_draftfinalOMB 05.29.2025.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 86

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	86	86
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.